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11 Waste Tire Su y & Inspection Rel <br /> ort#lnspection Report Number ■ <br /> State ofCalifornia <br /> CIWMB181(New04/04) Survey Form - Page 1 .1 . 1 - 1 01 4 7 . <br /> California Integrated Waste Management Board <br /> Part A- Surveyy BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: 2 q (� - 0 ( QI Routine 0 Re-inspection Q Referral Q Observation. <br /> Local /"` If Referral,choose referral type(Fill one) <br /> Identifier: ✓ 1_ O CHP Q CIWMB 0 Complaint 0 Educational Visit Q.Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> StFeisf <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM AM <br /> � m0m ' m <br /> PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ) (Fill one only) (Fill all that aPPIY) (Fill all that a (Fill all that aPPIY) <br /> Tire Count Whole/PTE <br /> Active Passenger Generator <br /> 0 Outdoor <br /> Latitude m D 0 Closed Altered 0GPS Hauler @ Indoor <br /> D O Inactive 0 Truck <br /> Longitude - O Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that a ply) <br /> Q New Tire Dealer o Au`o Repair (tTrucking Fleet, Q Government O Retreader 0 Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder Q Other I I <br /> Part.B -`Inspection of Waste Tire Dealer, Generator, Hauler_ and End-Use Facility ENFORCEMENT STATUS <br /> V ' A !HAULING AND MANIFEST REQUIREMENTS o Notice Of Violation Q Ektension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible.Entities Complying with Manifesting Requirements Date m m m <br /> 0 Q 14 CCR§18459.1 (a)(b)(c)-Tite Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0- 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance --No Violations <br /> 0 O Other: § <br /> Comments /I <br /> G v` 7(2 �T S. �C r�•-^-, !::�• �(I--�'-s ,kms ' t/,.��:_.L' `� /.- ^,C� <br /> Inspection Form Included: 0' ' <br /> Comments Included: -` r <br /> Business Re 's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: (X) ` V EIXI.AIMI PT E l 1 C <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 1 <br /> fr - <br />